Current guidelines recommend interdisciplinary management, emphasizing 3 core treatment elements pain management, rehabilitation, psychological treatment. The best therapeutic regimen has not been established. Increasing evidence suggests that some cases are refractory to conservative measures and require flexible application of various treatments as well as early consideration of invasive interventions.

Stimulation produces paresthesia over large areas of selected regions corresponding to level of cathode below

56Illustration of Multiple IndependentCurrent Control FractionalizationMultiple Independent Current Control One Current Source for Each ContactSingle-Source Control One Voltage or Current Source for All ContactsIIIV/IV/I 57Spinal Cord Stimulation

EFFICACY

Most studies are retrospective and report a 50-70 success rate (gt50 reduction in pain) with follow-ups ranging from 3-7 years

North, 1993 Kumar, 1991

Studies on re-operation for failed back demonstrate poor outcomes

North, 1991

Studies using improved technology have not been done

58Spinal Cord Stimulation 59Spinal Cord Stimulation

ECONOMICS

Review of 14 patients, on average, recipients of SCS paid for itself within 5.5 years. In patients in whom SCS was clinically efficacious, the system paid for itself within 2.1 years

Bel and Baner, 1991

Studies are lacking using the newer rechargable battery technology

60Determining Level of Evidence Agency for Healthcare Research and Quality Criteria

Strong At least one properly designed randomized, controlled trial of appropriate size OR multiple properly designed studies of smaller size OR at least one randomized trial supplemented by prospective and/or retrospective evidence

Moderate well designed small randomized trial OR well designed trials without randomization OR quasi-randomized studies, single group, pre-post cohort, time series OR matched case-controlled studies OR at least one meta-analysis

Limited well designed non-experimental studies from more than on center or research group

Intermediate opinions of respected authorities, based on clinical evidence, descriptive studies, or reports of expert committees

The efficacy of interventional therapies for pain management is difficult to determine due to the challenges of clinical trial design

Most trials are retrospective and of the prospective randomized trials, very few are blinded

As a single therapeutic modality, interventional therapies are less likely to be effective than when applied with comprehensive management including medical, psychological and rehabilitative therapies

Beware of the Block Shops

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